Rockwood Adults CH34

1119

CHAPTER 34 • Glenohumeral Instability

Positioning The patient is positioned in the lateral decubitus position with the operative extremity facing superiorly. Pillows are used between the knees, and the contralateral arm is positioned in forward flexion at the shoulder with the elbow flexed into a comfortable position. The neck is positioned in neutral. A bean bag, peg board, or commercially available positioning system is then utilized to secure the patient in the lateral position and then secure the patient to the table (Fig. 34-43A). A pneumatic arm holder or traction system is secured to either the anterior or posterior aspect of the bed, according to surgeon preference, and provides in-line traction. A separate paddle or abduction cable is placed about the operative arm to provide abduction. When this is completed, then the shoulder is prepped and draped to allow circumferential access. Beach chair position and set up can also be used for this procedure. The patient is sat up to 60 to 70 degrees with all prominences well padded. An arm holder is used to assist in the arm positioning. A small bump can also be used to help distract the glenohumeral joint. An advantage of the beach chair posi- tion is that the arm can be positioned to help better expose the joint. Internal rotation will help open up the anterior capsule while external rotation will help open up the posterior capsule. Surgical Approach Surface anatomy—including the lateral clavicle, the acromion and spine of the scapula, and the coracoid—is marked out on the skin prior to the start of the case. Standard arthroscopy portals are created which include a posterior initial viewing portal, an anteri- or-inferior portal just above the upper border of the subscapularis,

Arthroscopic Capsular Plication Preoperative Planning ✔ ✔ Arthroscopic Capsular Plication:

PREOPERATIVE PLANNING CHECKLIST

❑❑ Regular table is used for lateral decubitus position

OR table

❑❑ Bean bag is used to obtain lateral decubitus position ❑❑ Pneumatic arm holder to provide longitudinal traction and allow internal/external rotation of the shoulder ❑❑ Separate abduction paddle

Position/ positioning aids

❑❑ 30- or 70-degree arthroscope ❑❑ 6- or 8-mm threaded cannulas ❑❑ Switching sticks

Equipment

❑❑ Percutaneous insertion kit and double-loaded 2.4-mm suture anchors for use in anterior- inferior and posterior-inferior margin of glenoid. Alternatively, labral tape and knotless fixation with pushlock anchors can be used as well. ❑❑ If the labrum is intact, use alternate no. 1 absorbable polydioxanone (PDS) suture with suture anchors ❑❑ Knotless suture anchors (2.9-mm anchor with no. 2 high tensile strength suture, or looped suture, or suture tape) ❑❑ Arthroscopic rasp and liberator, CoVator ❑❑ Arthroscopic shaver ❑❑ Suture passer with multiple angles usually needs at least a curve to the right, a curve to the left, and a straight passer for pan-capsular plication

Other

A

B

Figure 34-43.  A: Lateral decubitus position for arthroscopic capsular plication or shift in a patient with multidirectional instability. B: Diagnostic arthroscopy indicates a positive “drive-through” sign ( blue arrow ) with capsular laxity and joint mobility.